Multitable New Patient Form

Health Care Consumer Questionnaire
Patient Name _____________________________ DOB ____/____/________ Date ____/____/________

In order to best serve your medical needs, we ask that you complete the following questionnaire as completely
as possible. The Health Care Consumer (HCC) - Health Care Provider (HCP) relationship is a privileged
relationship built on trust and honesty. By completing and signing this form, you acknowledge that you
understand that any intentionally false information may seriously and adversely affect your health.
Patient Name Gender M F

Date of Birth (MM/DD/YYYY Social Security Number
Reason for Visit
If the person completing this form is not the patient, please write your name, your relationship to the patient, and
why the patient is unable to complete the form.
Name Relationship to Patient
Reason
Health Care Consumer’s Address Phone

Home
Work
Cell
Emergency Contact (Address and Phone)

Home
Work
Cell
Insurance Information Phone
Policy #
Additional, or Secondary Insurance Company
Policy #
Have you designated a Durable Power of Attorney for Health Care? Yes No
If yes, please provide a copy for your health care provider.
Do you have any religious or cultural beliefs that may impact your health care? If yes, Yes No
describe
I best learn new information by: Verbal Instruction Written Instruction Handouts Pictures
Level education completed <6th grade 6th – 9th grade 12th grade 1-4 years college >4 years college
I understand English well Yes No If NO, please specify the language you prefer
MB & RR 2008 e-medtools.com 1

The information on this page was reviewed with the patient HCC Initials ____ HCP Initials _____
Names and Phone Numbers for Health Care Providers (HCPs) from whom you are currently receiving
care (or have seen within the past 12 months), or from whom you have received prescriptions.
Contact #
Contact #
Contact #
Contact #
Contact #
Contact #
Please list all of the medications you are taking. Include over the counter medications, herbs &
vitamins.
Medication Name Dose Last taken Medication Name Dose Last taken
Please list and describe allergic reactions you have had to food, medications or insect stings.
Check if you are you allergic to Shellfish ___________ IV Contrast Dye __________ Penicillins __________
Please list other Food, Medication or Insect Allergies Describe your reaction
Please list your occupations. Include the length of time you performed in that role, and describe
your work responsibilities in that occupation. (Include military experience.)
Occupation Start Date Stop Date Responsibilities

Have you ever been exposed to known cancer causing agents or inhalation hazards? Yes No
Examples: asbestos, paints, aniline dyes, chemicals, silica, etc.
Agent Exposure time Problems related to exposure
Please describe your hobbies.
Have you traveled, in the past 1 year? Yes No

Travel destinations OUTSIDE the United States Dates spent at this destination
Travel destinations INSIDE the United States Dates spent at this destination
Exercise History
Do you exercise? Yes No If yes, describe how long and how often you exercise on average each week
History of Falls
In the past 12 months, have you fallen? Yes No
If yes, how many times?
If yes, have you ever broken bones, or sustained an injury, as a result of falling? Yes No
Vaccination History Have you ever had any of the following vaccinations?
Vaccine Date of last vaccination
Influenza Yes No
Pneumonia Yes No
Tetanus Yes No
BCG Yes No
Varicella Yes No
HPV (Gardasil) Yes No

Tobacco Use History If yes, describe

Have you ever smoked? Yes No # packs per day X # years
Have you chewed tobacco? Yes No
Have you smoked pipes or cigars? Yes No #cigars or pipe bowls per Day Week
Have you quit? Yes No When
Have you consider quitting? Yes No Have you set a date? Yes No
Have you tried quitting? Yes No What was the longest time you quit?
Alcohol Use History If yes, describe

Do you now, or did you once, regularly drink alcohol? Yes No # drinks per Day Week
1 “drink” is equal to 12 oz. can of beer, 1.5 oz. liquor (80 proof) or 5 oz wine
Have you ever “blacked out” due to alcohol intake? Yes No
Have you had a drink to prevent the “shakes”, “sweats”, or developing other problems? Yes No
Have you ever been arrested or ticketed for DUI (Driving Under the Influence)? Yes No
Have you been involved in any motor vehicle accidents in the past 12 months? Yes No
Recreational Drug Use History
Do you now use, or have you ever used, drugs for recreational purposes? Yes No
If yes, check all that apply Amphetamines Cocaine Marijuana Heroin Inhalants LSD
Describe the method of delivery you chose Ingestion Injection Inhalation
Have you quit? Yes No
Have you ever taken drugs to prevent the “shakes”, “sweats”, or developing other problems? Yes No
Have you ever had a problem with addiction to prescription pain medication or benzodiazepines Yes No
(like Valium, Xanax, etc.)?
Hepatitis, HIV and STD risk factors

Are you sexually active? Yes No
If yes, do you practice birth control? Yes No
What birth control method do you use? Check all that apply
Condoms Diaphragm IUD (Intrauterine Device) Birth Control Pills, Patches, Implants
How many sexual partners have you had in the past 1 year? Specify here
Have you ever had sex with a person who is the same gender as yourself, bisexual, Yes No
or anyone who performs sexual favors in exchange for money or drugs?
Have you EVER been diagnosed with a sexually transmitted disease “STD” (like syphilis, Yes No
gonorrhea, chlamydia or HIV), or were you exposed to a STD during childbirth?
Do you have any tattoos or body piercings? Yes No
Have you received any transfusions of blood or blood products? Yes No
Seatbelt Use
Describe your seatbelt use when you are driving, or a passenger in a vehicle
All the time Most of the time About half the time Rarely Never
Firearm Safety
Do you keep firearms in your place of residence? Yes No
If yes, are they kept in locked compartments, or do they have safety locks? Yes No
Can you perform your own hygiene, dressing, cooking and shopping needs independently? Yes No
Have you ever been in a relationship where you were threatened, hurt or afraid? Yes No

Prior Diagnostic Tests Have you ever had any of the following exams?
Test Response Approximate date and Reason
PAP Smear Yes No
Prostate Biopsy Yes No
Mammogram Yes No
Colonoscopy Yes No
EGD (Esophageal endoscopy) Yes No
EKG Yes No
Cardiac stress test Yes No
ECHO Yes No
Chest x-ray Yes No
CT “CAT” scan of chest Yes No
Pulmonary function test Yes No
EEG Yes No
Bone density test Yes No
Female Patients Only

Response Descriptions
Have you ever been pregnant Yes No
# of pregnancies
# Live Births
# Miscarriages, Abortions
Your age at onset of menstruation
Your age at onset of menopause NA
Have you ever taken birth control pills, or used patches or implants? Yes No
If yes, how long
Have you ever used hormone replacement therapy? Yes No
If yes, how long
Did you ever have an IUD (Intrauterine Device) implanted? Yes No
If you had an IUD, was it removed? If yes, when Yes No
Surgical History
Surgery or Procedure Date of Procedure Name of Provider Performing Procedure

Past Medical History Please check all that apply.

Adrenal Dysfunction Yes No Irregular Heart Rhythm Yes No
Alzheimer Yes No Kyphosis Yes No
Amyotrophic Lateral Sclerosis Yes No Liver Dysfunction Yes No
Anorexia or Bulimia Yes No Kidney Failure, or Dysfunction Yes No
Anxiety Disorder Yes No Malignancy If yes, describe below Yes No
Arteriovenous Malformations (AVMs) Yes No
Arthritis Yes No
Asthma Yes No Mania Yes No
Autoimmune Disease Yes No Muscular Dystrophy Yes No
Bipolar Disorder Yes No Myocardial Infarction (Heart Attack) Yes No
Bleeding Disorder Yes No Narcolepsy Yes No
Cataracts Yes No Obstructive Sleep Apnea Yes No
Cerebrovascular Accident (Stroke) Yes No Organ Transplant If yes, describe Yes No
Chemotherapy If yes, state when Yes No
Osteoporosis Yes No
Claudication Yes No Pancreatitis Yes No
Clotting Disorder Yes No Periodic Limb Movement Disorder Yes No
Congenital Heart Defects Yes No Peripheral Artery Disease Yes No
Coronary Artery Disease Yes No Personality Disorder Yes No
COPD Yes No Pituitary Dysfunction Yes No
Cystic Fibrosis Yes No Polycystic Ovarian Syndrome Yes No
Depression Yes No Pulmonary Artery Hypertension Yes No
Diabetes Yes No Pulmonary fibrosis Yes No
Dialysis Yes No Radiation Therapy If yes, explain Yes No
Eclampsia or Pre-eclampsia Yes No
Endocarditis Yes No Recurrent Infections Yes No
Endometriosis Yes No Restless Leg Syndrome Yes No
End Stage Renal Disease Yes No Sarcoidosis Yes No
Erectile Dysfunction Yes No Schizophrenia Yes No
Esophageal Dysfunction Yes No Scleroderma Yes No
Fibromyalgia Yes No Scoliosis Yes No
Gallstones Yes No Seizure Disorder Yes No
Gastritis or Gastric Ulcers Yes No Sickle Cell Yes No
GERD (reflux problems) Yes No Sjogren Yes No
Glaucoma Yes No Skin Disorders (Psoriasis, Acne) Yes No
Heart or Valve Defects Yes No Thalassemia Yes No
Hemochromatosis Yes No Thrombocytopenia Yes No
Hemorrhoids Yes No Thrombophilia Yes No
Hepatitis Yes No Transfusions Yes No
HIV or AIDS Yes No Tuberculosis Yes No
Hypertension Yes No If yes, have you been treated? Yes No
Hyperthyroidism Yes No Urinary retention or urgency Yes No
Hypotension Yes No Vasculitis Yes No
Hypothyroidism Yes No Visual defects Yes No
Inflammatory Bowel Disease Yes No Vocal cord dysfunction/paralysis Yes No

Review of Systems In the last 6 months, have you experienced any of the following symptoms? Respond to each.
Constitutional Genitourinary
Weight Loss or Gain Yes No Blood in your urine Yes No
Appetite changes (increased or decreased) Yes No Menstrual changes Yes No
Fatigue, profound and impairs daily function Yes No Urinating that is painful or difficult Yes No
Fever Yes No Erection problems Yes No
Shakes/sweats from lack of alcohol or drug Yes No Vaginal discharge or bleeding Yes No
Eyes Musculoskeletal
Eye pain or drainage Yes No Broken bones Yes No
Visual changes Yes No Joint pain or swelling Yes No
Dry, irritated eyes Yes No Muscle aches Yes No
ENT/Mouth Muscle weakness Yes No
Ear pain or drainage Yes No Back pain Yes No
Frequent sinus infections Yes No Skin/Breasts
Hearing changes or loss Yes No Masses or lumps Yes No
Nosebleeds Yes No Nipple discharge Yes No
Dizziness Yes No Rashes or nonhealing ulcers Yes No
Respiratory Neurologic
Blood in your sputum Yes No Seizures Yes No
Chest tightness Yes No Coughing or choking with swallowing Yes No
Cough lasting >1 month, productive or not Yes No Excessive daytime sleepiness Yes No
Shortness of breath Yes No Extremity pain or burning sensations Yes No
Wheezing Yes No Hallucinations Yes No
Chest pain with inhalation or coughing Yes No Numbness or tingling Yes No
Cardiovascular Difficulty falling asleep, staying asleep Yes No
Chest pain or heaviness Yes No Endocrinologic
Palpitations Yes No Hair loss Yes No
Fainting or near fainting spells Yes No Frequent urination Yes No
Swelling of feet or legs Yes No Increased thirst Yes No
Shortness of breath lying flat in bed Yes No Heat or cold intolerance Yes No
Gastrointestinal Heme/Lymph
Abdominal pain Yes No Bleeding from gums or nose Yes No
Blood in your stool Yes No Unexplained bruising Yes No
Constipation Yes No Night Sweats Yes No
Diarrhea or Food Intolerance Yes No Swollen, painful lymph nodes Yes No
Heartburn or Indigestion Yes No Allergy/Immun
Vomiting or nausea lasting for >1 day Yes No Watery eyes Yes No
Swallowing difficulty Yes No Runny nose Yes No
Psych Food intolerance Yes No
Anxiety without clear explanation Yes No Frequent skin sores Yes No
Sadness lasting for days or weeks Yes No
Hearing voices Yes No
Thoughts of hurting yourself Yes No
Thought of hurting others Yes No
Fear of people, places or things Yes No

Family Medical History

(M=Mother, F=Father, B=Brother, S=Sister, So=Son, D=Daughter, GM=Grandmother, GF=Grandfather, M in front = Maternal P = Paternal)
Medical Problem Family Members Affected
M F B S So D M-GM M-GF P-GM P-GF
Referral Information – We would appreciate learning how you heard about us? Check one, please
Another physician, nurse practitioner or physician assistant?
If so, please specify who:
Family member or friend who is a patient of this clinic
Family member or friend who is NOT a patient of this clinic
Sign outside your office
Billboard Ad
Media Ad Please specify Television Radio Newspaper Ad
Hospital referral service
Phone book
Internet
Other, please specify
Additional Information that you feel may be helpful for your health care provider to know.
Health Care Provider Notes


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Health Care Consumer Questionnaire

Patient Name _____________________________ DOB ____/____/________ Date ____/____/________

Patient Name Gender M F

Reason for Visit

Health Care Consumer’s Address Phone

Emergency Contact (Address and Phone)

Insurance Information Phone

Additional, or Secondary Insurance Company

MB & RR 2008 e-medtools.com 1

Patient Name _____________________________ DOB ____/____/________ Date ____/____/________

MB & RR 2008 e-medtools.com 2

Patient Name _____________________________ DOB ____/____/________ Date ____/____/________

Please describe your hobbies.

Have you traveled, in the past 1 year? Yes No

MB & RR 2008 e-medtools.com 3

Patient Name _____________________________ DOB ____/____/________ Date ____/____/________

Tobacco Use History If yes, describe

Alcohol Use History If yes, describe

Hepatitis, HIV and STD risk factors

MB & RR 2008 e-medtools.com 4

Patient Name _____________________________ DOB ____/____/________ Date ____/____/________

Female Patients Only

MB & RR 2008 e-medtools.com 5

Patient Name _____________________________ DOB ____/____/________ Date ____/____/________

Past Medical History Please check all that apply.

MB & RR 2008 e-medtools.com 6

Patient Name _____________________________ DOB ____/____/________ Date ____/____/________

MB & RR 2008 e-medtools.com 7

Patient Name _____________________________ DOB ____/____/________ Date ____/____/________

Family Medical History

Health Care Provider Notes

MB & RR 2008 e-medtools.com 8

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